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More MS news articles for July 2003

A woman's secret shame: urinary incontinence

Millions suffer in silence and isolation, but medication, exercises and surgery offer hope

July 28, 2003
By Sherry Jacobson
The Dallas Morning News
SOURCE: Dallas Morning News research

Of all the experiences Lorna Scott has shared with her husband since they took up motorcycle riding, the most embarrassing may be the time she wet her pants at a motorcycle rally they attended in Arkansas.

"I swung my leg off ... [my] bike and just flooded myself," the 57-year-old Cleburne resident recalls of that moment a year ago. "I tried to cover it up by tying my jacket around the back and holding my purse in front. We had to leave immediately."If she had followed the pattern of most women who suffer such episodes of urinary incontinence, Ms. Scott would have gone home, parked her Yamaha Ventura in the garage and stayed away from motorcycle rallies for the rest of her life.

More than half of the 8 million women in the United States who are believed to suffer from urinary incontinence have never seen a doctor about it. Research indicates that women often misconstrue such accidents as a hygiene problem they must cope with rather than a medical problem that needs a doctor's attention.

 "I couldn't sneeze, laugh or do anything, and I'd be leaking," recalls a 74-year-old Dallas woman who asked not to be identified. Her incontinence got gradually worse for almost a decade before she sought help. "If the doctor would ask about it, I'd say, 'It's not all that bad. I'm controlling it.' Well, I was almost controlling it."

Incontinence can be treated with physical therapy, medication and surgery, all of which are covered by most health insurance plans. Many kinds of doctors, including family practitioners, urologists, gynecologists and a new subspecialty of urogynecologists, say they are trained to handle incontinence. But it might take a specialist to figure out the underlying cause.

"It's not that easy to diagnose because there are different types of incontinence," says Dr. Michael E. Carley, director of urogynecology at Baylor University Medical Center at Dallas. "And many women have more than one type."

The most common bladder control problem suffered by women is stress incontinence, which usually results from certain muscles becoming too weak to keep the bladder tightly closed. Women with this condition can leak urine when they sneeze, laugh, cough or lift a heavy object.

Urge incontinence, the second most common type, occurs when a person feels an overwhelming need to urinate when the bladder is not full. Also known as overactive bladder, the condition can result from a bladder infection, nerve damage, over-consumption of alcohol and taking certain kinds of medication, such as diuretics.

Researchers believe that urinary incontinence most often results from physical changes in women's bodies possibly from a combination of weight gain; the loss of hormones as women age; and the lingering effects of childbirth, especially multiple deliveries, and previous gynecologic surgery.

Such gender-specific changes may explain why women are more likely than men to lose control of their bladders. Quite simply, the network of muscles and nerves that support the bladder tend to malfunction more often in women's bodies than in men's, experts say.

"Women are approximately four times as likely as men to suffer from urinary incontinence when younger than 60 years of age," concludes Dr. Mikio Nihira, a Dallas urogynecologist whose overview on female incontinence will be published next month in the journal Current Women's Health Reports. "However, women are only twice as likely to have urinary incontinence among individuals older than 60 years of age."

Urinary incontinence, as experienced by older men, is most often associated with enlargement of the prostate but can also result from multiple sclerosis, spinal cord injury, stroke, bladder cancer and even kidney stones.

"Unfortunately, most research until fairly recently has focused on men," says Dr. Nihira, "even though urinary incontinence has always been a fairly substantial problem for women."

Significant success

Treatments for incontinence have shown significant success in restoring some measure of bladder control.

Research has shown a 90 percent or better improvement in stress incontinence by using certain surgical procedures to shore up failing bladder muscles. However, such good outcomes don't promise a complete and immediate cure for everyone. Success depends on correctly matching the diagnosis with the appropriate treatment, which can require more than one attempt, doctors say.

Several drugs developed to treat urge incontinence also have shown as much as 80 percent effectiveness in calming bladder contractions that falsely signal the need to go to the bathroom. However, some users report such side effects as dry mouth and constipation.

A study in the July 16 issue of The Journal of the American Medical Association found that episodes of stress incontinence could be reduced by about 70 percent with certain behavior changes, including teaching women how to exercise the muscles that control their bladder. Over eight weeks, participants were taught how to contract and relax muscles selectively while lying, sitting and standing.

"Exercise usually can cure up to one in three incontinent people without medication or surgery," says Dr. Patricia Goode, the study's lead author and an incontinence expert at the University of Alabama at Birmingham.

"But we also try to get women off caffeine," she says. "Studies have shown that caffeine makes the bladder more irritable, which can be a contributing factor to incontinence."

Doctors say that the hardest part of treating women for incontinence may be getting them to seek help in the first place.

"Many [incontinent] women feel they are alone, and they feel reluctant to raise the issue with their family or health-care provider," Dr. Carley says.

"It is still hidden," agrees Dr. Goode, a geriatrician who has published three studies about female incontinence. "Only one in three patients will tell her doctor she has urine leakage. They're just so embarrassed about it."

When women finally seek treatment they often describe how they gradually altered their lives to accommodate their incontinence, doctors say. Women admit to changing jobs or even switching careers if it improves their access to a bathroom. They shun social gatherings or resort to wearing adult diapers or thick sanitary pads on outings. And as the problem worsens, many stay home to be within safe distance of a toilet.

Dr. Nihira, who practices at the University of Texas Southwestern Medical Center at Dallas, recalls a patient who limited outings to less than seven hours at a stretch because she so feared she would become incontinent in public. And for 17 years, she sent her family on vacations without her.

"I had another incontinence patient, a kindergarten teacher, who developed a way to signal her colleagues to watch her class 10 to 15 times a day so that she could use the toilet," he says. "And that went on for seven years."

Workplace issue

Indeed, incontinence often can be a workplace issue for women, says Mary H. Palmer of the University of North Carolina Chapel Hill School of Nursing. Her study of female employees published last year in the Journal of Women's Health suggested that 20 percent to 30 percent of middle-aged workers suffer incontinence at least once a month. Yet fewer than half seek help from a doctor.

"The majority of women with incontinence thought it was not important or even slightly important to get treatment," Dr. Palmer says of her two surveys of 2,500 women who worked either in an academic setting or a rural pottery factory. Still, those who suffered incontinence overwhelmingly indicated that they wanted more information about the problem.

"Some of the women wrote comments in the survey's margin saying they didn't realize this problem even had a name or that they should mention it to their doctor," Dr. Palmer notes. "But some also admitted they were keeping extra underwear at work in case of an accident or were distracted at meetings because they needed to get to a bathroom."

Ms. Scott says she waited only a short time before seeing her doctor after the "accident" at the motorcycle rally. By then, she had learned the location of every bathroom in every store that she shopped in regularly, and she was using eight to 10 sanitary pads a day.

Her doctor explained, she says, that her bladder was malfunctioning because it had fallen into the pelvic space vacated by her uterus, which she'd had removed three years earlier. Her doctor referred her to Dr. Nihira at UT Southwestern, who diagnosed her as having both stress and urge incontinence. In March, she underwent surgery, and later she began taking daily medication.

"I went from having no control to feeling like a normal person again," Ms. Scott reports. "I feel just wonderful, and I'm back on the bike again."

Treatments for urinary incontinence

A variety of treatments have been developed to try to restore urinary continence. They include:

Behavioral training also known as Kegel exercises Patients are taught how to identify, relax and contract their pelvic floor muscles, which support bladder control. A biofeedback monitor may be used to measure the effectiveness of the exercises.

Pelvic floor electrical stimulation Using a vaginal probe, patients or caregivers deliver a small electrical shock to the pelvic floor, which assists patient in locating and controlling muscles that support the bladder.

Vaginal cones Weighted cones are inserted temporarily into the vagina to train women to use their pelvic floor muscles. The muscles contract to prevent them from slipping out during 15 minutes of exercise.

Medications such as:


Tension-free vaginal tape Through a small vaginal incision, a permanent meshlike material is placed beneath the urethra and anchored to the abdominal muscles beneath the pubic bone.

Burch procedure Permanent stitches anchor the neck of the bladder and urethra to a ligament that attaches behind pubic bone.

Anterior vaginal wall repair The vaginal wall is folded and stitched to bring the bladder and urethra into the proper position.

Sacral neuromodulation A pacemakerlike device is implanted in the lower back and delivers small repetitive electrical impulses to stimulate nerves of the bladder.

Artificial urinary sphincters A device implanted in the abdomen simulates the function of the urinary sphincter, the muscle that opens and closes the bladder.

Other procedures:

Periurethral bulking injections Substances such as collagen or carbon-coated beads are injected into the tissue surrounding the urethra to increase bulk and resistance to the outflow of urine.

Intraurethral inserts A device is inserted into the urethra to prevent urine from leaking for a short period of time, such as while exercising. Designed for one-time usage.

Incontinence dish or pessary A silicone or latex device is placed in the vagina at the base of the bladder, applying enough pressure to keep the bladder closed. Also called an incontinence ring pessary, the device comes in a many sizes and styles that can be worn for days or weeks at a time.

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